Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to notify the State agency of an allegation of verbal abuse by a staff member towards a resident. The incident involved a resident with multiple diagnoses, including bipolar disorder, schizoaffective disorder, and moderately impaired cognition. On the date of the incident, a hospice aide reported to the facility administrator that a certified nursing assistant (CNA) had spoken loudly and aggressively to the resident, threatened to take away the resident's call light, and displayed behavior that upset the resident. The hospice aide also reported the incident to her own supervisor, and the hospice director confirmed that an occurrence was entered into their records. Despite being informed of the incident by both the hospice aide and another CNA, the facility administrator did not initiate a self-reported incident (SRI) or conduct an investigation. The administrator stated that after speaking with the hospice aide, she did not believe the incident was reportable and therefore did not notify the State agency. There was no documentation of the incident in the resident's medical record, and the administrator did not interview the CNA involved, the resident, or other staff present at the time. The CNA continued to work scheduled shifts and was not removed from resident care or provided with additional education regarding abuse or customer service. Interviews with the resident revealed that she felt verbally abused by the CNA, had reported previous incidents to the DON and ombudsman, and expressed fear and discomfort regarding the CNA's care. The resident described the CNA as yelling, intimidating, and making derogatory remarks about her preferences. The facility's policy required timely reporting and investigation of all alleged abuse, including immediate removal of accused staff from resident care, but these procedures were not followed in this case.